Insurance Company Denies Coverage for Drug - Part II

Last week, I related a vignette where a routine medication refill was denied by a patient's new insurance company.  The patient had developed symptoms 2 weeks after he ran out of the medication. I surmise that 100% of gastroenterologists surveyed would have agreed that refilling the medication was the next step.

So, even though the best medical option was to refill the medicine that we know has worked, the new insurance company won’t cover it and the patient cannot afford to pay retail for the drug. (As a separate point, I challenge anyone including those with PhD's in economics to explain retail drug pricing.)  The patient did his best to navigate the insurance company’s website and found a colitis medicine that is covered, but it is medically inferior.  Should we just cave and prescribe it to save money and a hassle?  Is this an issue that we want on our sick patients' agendas?  How would you like to face surgery and be told that the newer clamps and scalpels are out of network, but there are some rusty tools in the back that are fully covered?

I tried using our electronic medical record to ascertain if there were effective alternative colitis medications that would be covered, but neither me nor my staff could get a straight answer on this.   If we were to call the pharmacist to ask which colitis medicines were covered, which we have tried in the past, we would be told that we would have to officially prescribe each drug individually in order to determine its coverage status.  Doesn’t that sound fun and efficient?

Does this vignette show medical care at its finest?  How much time do physicians and our staffs burn up on tasks like these?   Does this anecdote reinforce the notion that insurance companies’ mi$$ions are to protect profits and not patients?

Do we want sick patients and physicians to have to fight just to get medicines approved?  Shouldn’t they be focused on health and healing?   Keep in mind that my patient was not seeking exotic or experimental treatment.  He only wanted the medicine that he and I knew could keep him well which is approved by the FDA for his condition. 

Beware the Medicare for All Express!

If an avaricious shoe manufacturer decides to hike prices, no customer will be harmed.  If the insurance industry, however, aims to maximize their profits, folks can get sick or worse.  If this industry doesn’t reform itself, then at some point others will do it for them.  Wouldn’t they be wiser to earn some good will with their customers and the public rather than create an army of enemies? 

Who will be there to defend private insurance companies once the Medicare for All Express gains momentum?   If insurance companies won’t do the right thing for the right reasons, perhaps, self-preservation will motivate them to do better.